NS 660 Exam 2 Q&A
Which statement would indicate the need for further teaching?
A. If skin area gets red but red goas away after turning, I should report it to the nurse
B. Putting foam pads under the heels or other bony prominences can help decrease pressure
C. If a person cannot turn himself in bed, someone should help them change position every 4
hours
D. Skin should be washed with only warm water (not hot) and lotion put on wile it is still little
whet - =C. If a person cannot turn himself in bed, someone should help them change position
every 4 hours
Rationale:
This should happen every 2 hrs.
Wound draining thick yellow material. What type of drainage? - =Purulent
Client enters ED after motor cycle accident, resulting in skidding across pavement. Client
wearing shorts, so large areas skin ripped off. Best describe this wound as:
A. Abrasion
B. Approximated
C. Laceration
D. Eschar - =C. Laceration
,Key word: Ripped
Laceration because large amounts of skin ripped off.
Although abrasion is usually related to road rash, the large amount of skin damaged is why it is
considered a laceration
Nurse caring for patients with variety of wounds. Which wound will most likely heal by primary
intention?
A. Cut in skin from kitchen knife
B. Excoriated perineal area
C. Abrasion of the skin
D. Pressure ulcer - =A. Cut in skin from kitchen knife
3 other options will heal by secondary intention
Nurse preparing to measure depth of client's tunneled wound. Which of the following tools
should nurse use to measure depth accurately?
A. Otic curette
B. Sterile tongue blade lubricated with water soluble gel
C. Sterile flexible applicator moistened with saline
,D. Small ruler - =C. Sterile flexible applicator moistened with saline
Older patient is most likely to experience which of the following changes with aging?
A. Thinning of epidermis
B. Thickening of epidermis
C. Oiliness of skin
D. Increased elasticity of skin - =A. Thinning of epidermis
Age causes thinning, decreased elasticity, and increased dryness.
Caring for client and notice a superficial ulcer on left hip that appears shallow crater, red pink
wound bed and no slough or eschar. Which stage would best describe the break in skin integrity?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
E. Unstageable - =B. Stage II
Stage I = no skin loss
, Minimal skin loss/shallow depth = stage II
Caring for client at high risk for developing pressure ulcers. Which of the following are intrinsic
factors that increase risk of pressure ulcers? Select All that Apply:
A. Friction
B. Impaired sensation d/t spinal cord injury
C. Poor nutrition
D. Shearing
E. Edema
F. Compression - =B. impaired sensation d/t spinal cord injury
C. Poor nutrition - specifically protein
E. Edema
Friction, Shearing, and Compression are extrinsic factors associated with risk of pressure injury.
Applying saline-moistened dressing to clients wound. Client asks, "Wouldn't it be better to let
wound dry out so scab can form?" Which is the most appropriate response?
A. Wounds heal better when moist wound bed is maintained
Which statement would indicate the need for further teaching?
A. If skin area gets red but red goas away after turning, I should report it to the nurse
B. Putting foam pads under the heels or other bony prominences can help decrease pressure
C. If a person cannot turn himself in bed, someone should help them change position every 4
hours
D. Skin should be washed with only warm water (not hot) and lotion put on wile it is still little
whet - =C. If a person cannot turn himself in bed, someone should help them change position
every 4 hours
Rationale:
This should happen every 2 hrs.
Wound draining thick yellow material. What type of drainage? - =Purulent
Client enters ED after motor cycle accident, resulting in skidding across pavement. Client
wearing shorts, so large areas skin ripped off. Best describe this wound as:
A. Abrasion
B. Approximated
C. Laceration
D. Eschar - =C. Laceration
,Key word: Ripped
Laceration because large amounts of skin ripped off.
Although abrasion is usually related to road rash, the large amount of skin damaged is why it is
considered a laceration
Nurse caring for patients with variety of wounds. Which wound will most likely heal by primary
intention?
A. Cut in skin from kitchen knife
B. Excoriated perineal area
C. Abrasion of the skin
D. Pressure ulcer - =A. Cut in skin from kitchen knife
3 other options will heal by secondary intention
Nurse preparing to measure depth of client's tunneled wound. Which of the following tools
should nurse use to measure depth accurately?
A. Otic curette
B. Sterile tongue blade lubricated with water soluble gel
C. Sterile flexible applicator moistened with saline
,D. Small ruler - =C. Sterile flexible applicator moistened with saline
Older patient is most likely to experience which of the following changes with aging?
A. Thinning of epidermis
B. Thickening of epidermis
C. Oiliness of skin
D. Increased elasticity of skin - =A. Thinning of epidermis
Age causes thinning, decreased elasticity, and increased dryness.
Caring for client and notice a superficial ulcer on left hip that appears shallow crater, red pink
wound bed and no slough or eschar. Which stage would best describe the break in skin integrity?
A. Stage I
B. Stage II
C. Stage III
D. Stage IV
E. Unstageable - =B. Stage II
Stage I = no skin loss
, Minimal skin loss/shallow depth = stage II
Caring for client at high risk for developing pressure ulcers. Which of the following are intrinsic
factors that increase risk of pressure ulcers? Select All that Apply:
A. Friction
B. Impaired sensation d/t spinal cord injury
C. Poor nutrition
D. Shearing
E. Edema
F. Compression - =B. impaired sensation d/t spinal cord injury
C. Poor nutrition - specifically protein
E. Edema
Friction, Shearing, and Compression are extrinsic factors associated with risk of pressure injury.
Applying saline-moistened dressing to clients wound. Client asks, "Wouldn't it be better to let
wound dry out so scab can form?" Which is the most appropriate response?
A. Wounds heal better when moist wound bed is maintained
